Mammogram Guidelines – What to Do Now?

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The U.S. Preventive Task Force Services (USPTF) has recommended that screening mammograms were no longer routinely required for women in their 40s and that self-breast exam is no longer advised. What!? Is this just cost-cutting or is this good medicine?

Mammogram Recommendation for Whom?

Before deciding how to react to these guidelines and whether to follow them or not, the first order of business is to put them in perspective in terms of your own personal and comprehensive health care plan. It is our position here at Maverick Health that neither doctors, task forces, organized medicine nor insurance companies should be in charge of your health and health care – you should.

Government agencies (like the USPTF), doctors and insurance companies exist to serve you – not to dictate to you. To get the most out of these services, you must be the one in charge. This means taking on more responsibility for knowing your own circumstances. That’s how you will be able to determine where you fit into these new guidelines. These government agencies come up with these recommendations for whole populations – but treatment decisions must be made by and for individuals.

Health Risk Screening in General

Cancer and, in fact, all health screenings are designed to discover and treat diseases that may not yet be causing symptoms. The goal of screening is early detection to (hopefully) cure but at least treat problems before they develop into chronic diseases or cause death.

Different people have different levels of risk for a long list of chronic diseases and cancers. Risks are the result of family history, personal lifestyle behaviors and, to some extent, luck. I wrote my book, A Nurse Practitioner’s Guide to Smart Health Choices, specifically to help non-medical readers determine their particular risk profile so they are able to direct their health and health care intelligently.

Different individuals have different risk tolerances and your choice about what to do about these recommendations depends a lot on your own personal risk tolerance. You may love taking risks. Does jumping out of airplanes sound fun to you? Or you may hate risk. Do you find stepping outside your own home so risky you dread doing it? Most of us fall somewhere in between these two extremes, but our attitudes about risk determine how we choose to handle our health and health care. One size does not fit all.

The USPTF Mammogram Recommendation

The USPTF recommendation statement was directed at “women 40 years or older who are not at increased risk for breast cancer by virtue of a known underlying genetic mutation (i.e. a strong family history of breast cancer or known BRCA 1 or BRCA 2 genes from prior genetic testing) or a history of chest radiation.” The six USPTF conclusions were:

  1. For biennial screening mammography in women aged 40 to 49 years, there is moderate certainty that the net benefit is small. Although the USPSTF recognizes that the benefit of screening seems equivalent for women aged 40 to 49 years and 50 to 59 years, the incidence of breast cancer and the consequences differ. The USPSTF emphasizes the adverse consequences for most women—who will not develop breast cancer—and therefore use the number needed to screen to save 1 life as its metric. By this metric, the USPSTF concludes that there is moderate evidence that the net benefit is small for women aged 40 to 49 years.
  2. For biennial screening mammography in women aged 50 to 74 years, there is moderate certainty that the net benefit is moderate.
  3. For screening mammography in women 75 years or older, evidence is lacking and the balance of benefits and harms cannot be determined.
  4. For the teaching of BSE (breast self exam), there is moderate certainty that the harms outweigh the benefits.
  5. For CBE (clinical breast exam) as a supplement to mammography, evidence is lacking and the balance of benefits and harms cannot be determined.
  6. For digital mammography and MRI as a replacement for mammography, the evidence is lacking and the balance of benefits and harms cannot be determined.

What I Tell My Patients

  1. My clinical concern and responsibility is taking care of individuals, not populations. A single case missed is one too many as far as I am concerned. Even though mammography is not the most perfect test in the world, particularly in women under age 50, the practice of combination screening with mammography, an annual clinical breast exam and monthly or bimonthly self breast exam is the best we’ve got at present in my opinion. I plan to continue to recommend a baseline mammogram between age 35 and 40 and will determine frequency after that based on each woman’s particular risks and her financial ability to pay for the mammogram. As for the issue of “adverse consequences” raised by the task force (i.e. anxiety surrounding testing or additional testing such as ultrasounds or biopsies if the mammogram is questionable), that is a non-issue in my opinion. A little anxiety surrounding screening or diagnostic testing pales in comparison to the anxiety associated with a diagnosis of breast cancer. If the mammogram is questionable additional testing clarifies an individual’s breast status at any age.
  2. For women 50 to 74 years I’ll continue to recommend annual breast surveillance consisting of screening mammography, annual clinical breast exam and monthly or bimonthly self breast exam.
  3. Breast cancer risk increases with age. For women 75 and older in good health I will continue to recommend annual breast surveillance consisting of screening mammography, annual clinical breast exam and monthly or bimonthly self breast exam. Exceptions are when women are in poor health and would not be good candidates for breast cancer treatment or women who tell me that if they learned they had breast cancer they would not want any treatment.
  4. This recommendation I really do not understand. What possible “harms” can come from examining one’s own breasts for lumps and who exactly would be harmed? Why anyone would recommend women stop self breast exams is beyond me. My sister picked up her own breast cancer with self breast exam only a few months after her mammogram missed it. Because she caught it early her treatment was less invasive and more likely to have resulted in a cure. I will continue to encourage and teach self breast exams to my patients.
  5. For clinical breast exam (done by your health professional at your physical exam) they are saying they don’t know if it does any good or not. I haven’t picked up many breast cancers that way over the years, but I’ve picked up a few. In my practice we recommend annual physical exams, though the “benefit” of those too is under question. It’s an opportunity to do a very detailed exam of the whole body (not just a gynecological exam), check on whether health screenings are all up to date, and teach things like self breast exams and self skin exams among other things.
  6. Digital mammography and breast MRI are also question marks as far as the task force is concerned. At present radiology centers are upgrading to digital and that will be the new standard. Skilled radiologists reading the films – whether plain or digital – are still an essential component. In in the last study I read radiologists are still beating the computers in reading digital mammograms. Breast MRIs are expensive and currently used only for high risk patients or as a follow up to abnormal mammograms.

Postscript on PAPs

Just a couple of days after the USPTF announced their new recommendations the American College of Obstetricians and Gynecologists (ACOG) in a press release announced their own new recommendations that PAP smears can now be delayed until age 21 and only need to be done every couple of years.

FYI: These two new recommendations released during the same week were completely coincidental. They were issued by two different and unrelated organizations and are in no way a “conspiracy” to deprive women of health care. For now mammograms are still being covered in the same way by insurance companies they have always been.

As for the PAPs, women younger than 21 who are sexually active should definitely see a health professional about their gynecological care every year. Topics for discussion are: birth control options, HPV vaccination, timing of PAP smears, sexually transmitted disease risks and safe sex practices.

Bottom line: The best person to take care of you is you. If you’re lucky you have a competent and understanding health professional in the form of a nurse practitioner, physician or physician assistant to help you and advocate for you. If you don’t – see if you can find one.

Your comments are welcomed.

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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